Intraoperative Requirements Research Articles

Perioperative outcomes in congenital heart disease: a review of clinical factors associated with prolonged ventilation and length of stay in four common CHD operations

ObjectivesPerioperative management strategies and outcomes for low-risk congenital heart disease (CHD) surgery vary between institutions. To date, no consensus exists on standardized management for pediatric patients undergoing cardiac surgery. This study seeks to benchmark the perioperative management of four common CHD lesions and explore clinical factors affecting postoperative outcomes. DesignA retrospective review of CHD procedures performed 2015-2020. SettingThe study was conducted at a single academic tertiary pediatric hospital. ParticipantsAll patients presenting for repair of ventricular septal defects (VSD), complete atrioventricular canal defects (CAVC), tetralogy of Fallot (TOF) and transposition of the great arteries (TGA) were reviewed. InterventionsDemographic and clinical data were collected; clinical outcomes were defined as postoperative length of ventilation (LOV) and hospital length of stay (LOS), divided into reference and prolonged course groups analyzed for variables associated with differences in outcomes. Measurements and Main Results931 patients were selected for review. Prolonged LOV and LOS in all cohorts were associated with longer operative, cardiopulmonary bypass and cross-clamp times; higher intraoperative requirements for inotropic support; more blood transfusions and higher opioid administration; lower pH pre-operatively and higher lactic acid post-operatively. Worse outcomes were associated with younger age in VSD, older age in TGA and lower weight in TOF and TGA. Worse outcomes were also associated with higher preoperative hematocrit in VSD and TOF and elevated preoperative blood glucose in VSD and TGA. ConclusionsA better understanding of clinical factors affecting outcomes may facilitate streamlining perioperative management strategies for pediatric patients undergoing low-risk cardiac surgery.

Early postoperative outcomes of modified del Nido cardioplegia in coronary artery bypass surgery in patients with low ejection fraction

Background: This study aimed to investigate the intraoperative and early postoperative effects of modified del Nido cardioplegia (DNC) compared to classic blood cardioplegia (BC) in patients with impaired left ventricular ejection fraction (EF) who underwent isolated coronary artery bypass grafting (CABG). Methods: A total of 123 patients (108 males, 15 females; mean age: 62.2±8.5 years; range, 42 to 78 years) with an EF of 35% or lower who underwent on-pump CABG were included in the retrospective study between December 2022 and December 2023. The patients were divided into two groups according to the type of cardioplegia used: Group 1 (n=74) was designated as the BC group, and Group 2 (n=49) was designated as the DNC group. The groups were compared in terms of aortic cross-clamp duration, cardiopulmonary bypass (CPB) duration, need for defibrillation during weaning from CPB, positive inotrope requirement, intra-aortic balloon pump requirement, postoperative troponin-I levels, postoperative atrial fibrillation occurence, postoperative prolonged ventilation, development of postoperative neurologic complications, need for reintervention due to postoperative bleeding, postoperative transfusion requirement, and EF values at one month after the operation. Results: There was no significant difference between the two groups in the terms of aortic cross-clamp and CPB duration (p=0.955 vs. p=0.816). Additionally, there was no significant difference in the need for intra-aortic balloon pump usage between the two groups (p=0.105). Dopamine and dobutamine usage were significantly lower in Group 2 (p=0.04 and p=0.05, respectively). The intraoperative requirement for defibrillation was significantly lower in Group 2 (p=0.01). In addition, troponin levels at 12 h postoperatively were significantly lower in Group 2 (p=0.03). The incidence of postoperative atrial fibrillation was significantly lower in Group 2 (p=0.02). Moreover, there was no significant difference in EF values at one month after the operation (p=0.08). Conclusion: In patients who underwent CABG with reduced EF, modified DNC provided myocardial protection comparable to classic BC. Additionally, the need for intraoperative defibrillation and postoperative inotropic agents, as well as the incidence of postoperative atrial fibrillation, were lower in patients operated with DNC.

Novel technique of switching TIVA and sevoflurane during epilepsy surgery for combined intraoperative motor evoked potentials monitoring and electrocorticography: an illustrative case report

BackgroundDuring epilepsy surgery, it is equally important to record electrocorticography (ECoG) for detecting epileptogenic activity and guiding brain resection, and to evaluate neuromonitoring data, particularly motor evoked potentials (MEP), for avoidance of postoperative neurological complications. However, sevoflurane, which is commonly used during recording of ECoG, may attenuate the MEP response. It enforces anesthesiologists and neurosurgeons to select one anesthetic agent over another, facilitating either ECoG or MEP monitoring.Case presentationIn the presented case of a 20-year-old man, who underwent surgery for temporal lobe epilepsy, a novel technique of neuroanesthesia was introduced, integrating initial induction of the total intravenous anesthesia (TIVA) with propofol (effect-site concentration, 2.3–3.0 μg/ml), its subsequent switching to sevoflurane (end-tidal concentration, 2.5%) for ECoG recording, and further change back to TIVA for MEP monitoring during brain resection.ConclusionsIntraoperative switch of anesthetic agents according to specific intraoperative requirements may be useful for cases of brain surgery requiring both ECoG recordings and MEP monitoring.

Infusion of 20% Human Albumin Reduces the Requirement of Intraoperative Intravenous Fluids in Patients Undergoing Open Gastrointestinal Oncosurgeries – A Randomised Controlled Study

Background and Aims: The optimal strategy for intraoperative fluid management in patients undergoing major abdominal oncosurgery remains undecided. The present study was undertaken to determine the effect of 20% intravenous (IV) albumin on the requirement of IV fluids (IVFs) during open gastrointestinal (GI) cancer surgeries. Methods: This randomised, double-blinded, controlled trial was conducted in a tertiary care centre from August to October 2022 after obtaining approval from the institutional ethics committee and informed written consent from the study subjects. Forty patients were randomised to either Group A (n = 20), receiving an IV infusion of 25 mL/h of 20% albumin, or Group C (n = 20), receiving an IV infusion of 25 mL/h of plasmalyte for 4 h (total 100 mL). Fluid and vasopressor administration was guided by systemic and pulse pressure variations. The primary outcome was the intraoperative requirement for IVF in the two study groups. The secondary outcomes included intraoperative IV vasopressor requirement, serum lactate levels, incidence of post-operative complications and length of hospital stay. Results: After the exclusion of three patients due to intraoperative bleeding, 37 patients were included in the final analysis. Patients in Group A (n = 19) required less IVF (3.92 ± 0.54 mL/kg/h) as compared to Group C (n = 18) (5.03 ± 1.20 mL/kg/h) (P < 0.001). Four patients (22%) in Group C required intraoperative noradrenaline IV infusion (P = 0.040). There was no significant difference between the two groups, regarding the mean intraoperative serum lactate values, incidence of post-operative complications and mean length of hospital stay (P > 0.05). Conclusions: A 100 mL of 20% human albumin as an IV infusion over 4 h reduced the requirement of IV fluid and vasopressor intraoperatively in patients undergoing open GI cancer surgery.

A comparison between 3D printed models and standard 2D planning in the use of metal block augments in revision knee arthroplasty.

The study focused on the ability to predict the need and size of femoral and tibial augmentation using standard two-dimensional (2D) templates and models created with three-dimensional (3D) printing in surgical planning. This observational cohort study included 28 consecutive patients (22 females, 6 males; mean age: 71±7.3 years; range, 54 to 82 years) with periprosthetic joint infection recruited between March 2021 and September 2023 undergoing revision total knee arthroplasty revision (TKA). Standard planning was made using calibrated X-ray images. The 3D planning started with computed tomography scans to generate a 3D template of the distal femur and proximal tibia. The model was exported to a 3D printer to produce a patient-specific phantom. The surgery was then simulated on the 3D phantom using revision knee arthroplasty instrumentation to evaluate the appropriate augmentation to use until a correct alignment was obtained. Three-dimensional planning predicted the need for femoral and tibial augments in 22 (78.6%) cases at both the tibial and femoral components, while 2D planning correctly predicted the need for augmentation in 17 (60.7%) for the tibial side and 18 (64.3%) for the femoral side. The Cohen's kappa demonstrated a significant agreement between the 3D planning for the femoral metal block and the intraoperative requirement (kappa=0.553), whereas 2D planning showed only nonsignificant poor agreement (kappa=0.083). In contrast, the agreement between 2D or 3D preoperative planning for tibial augment and the intraoperative requirement was nonsignificant (kappa=0.130 and kappa=0.158, respectively). On the femoral side, 2D planning showed only a fair nonsignificant correlation (r=0.35, p=0.069), whereas 3D planning exhibited substantial agreement with the actual thickness of the implanted augment (r=0.65, p<0.001). On the tibial side, 3D and 2D planning showed substantial agreement with the actual size of implanted augments (3D planning, r=0.73, p<0.001; 2D planning, r=0.69, p<0.001). Prediction based on 3D computed tomography segmentation showed significant agreement with the intraoperative need for augmentations in revision TKA. The results suggest that planning with 3D printed models represents a stronger aid in this kind of surgery rather than standard 2D planning, providing greater accuracy in the prediction of the required augmentation in revision TKA.

The Gore Viabahn balloon-expandable stent graft as a bridging stent in complex endovascular aortic procedures at 3 years performs better in fenestrations

ObjectiveComplex endovascular procedures are now recognized as the gold standard treatments for extensive aortic diseases. Bridging stents (covered stents used to couple the aortic graft to the visceral vessels) play a pivotal role, yet there is currently no dedicated device available on the market. The aim of the study was to evaluate the midterm performance of the Gore Viabahn balloon-expandable (VBX) stent graft as a bridging stent for target visceral vessels (TVVs). MethodsData from all consecutive patients who underwent a fenestrated and branched endovascular aortic repair and received the VBX stent graft as a bridging stent between July 2018 and September 2022 were prospectively collected and subsequently analyzed retrospectively. Primary end points included freedom from TVV instability and freedom from TVV-related reinterventions, both overall and in comparison between branched and fenestrated graft configurations. Secondary end points were overall survival, procedure and TVV-related (in an intent-to-treat basis) technical success, freedom from type IC/IIIC endoleak, and freedom from TVV patency loss. ResultsSixty-three patients were treated with a fenestrated and branched endovascular aortic repair using the VBX stent graft as a bridging stent, of whom 47 (74.6%) presented an atherosclerotic aneurysm, 7 (11.1%) a post-dissecative aneurysm, and 9 (14.3%) an anastomotic pseudoaneursym or a type IA endoleak in a previous endovascular aortic repair. Included in the aortic repair were 231 of 243 (95.1%) total visceral vessels. The intraoperative requirement of 13 additional VBX stent grafts determined a TVV-related technical success of 94.4%. The mean follow-up was 26.1 ± 16.4 months. The estimated overall survival at 36 months was 73% ± 7.5%. The estimated rates at 36 months for freedom from type IC/IIIC endoleaks and TVV primary patency were 90.6% ± 3.9% and 99% ± 0.7%, respectively. The estimated rate at 36 months for freedom from TVV instability was 92.1% ± 3% and did not differ between branched and fenestrated configurations, whereas freedom from TVV-related reinterventions was 90.6% ± 3.1% and significantly in favor of fenestrations (69.4% vs 96.8%, P < .001). Multivariate analyses confirmed fenestrated configuration as a protective factor against TVV-related reinterventions (hazard ratio: 0.079; 95% confidence interval: 0.016-0.403). ConclusionsThe VBX stent graft proves to be a reliable bridging stent for complex aortic procedures involving both fenestrated and branched endografts. Although immediate results are deemed satisfactory, they favor fenestrations regarding the need of reinterventions through 3 years. The success of the procedure heavily relies on a thorough understanding of the unique characteristics of this stent.

Assessing the Premedication Properties of Sublingual Melatonin in Young Women Undergoing Cesarean Section With Spinal Anesthesia: A Double-Blind Randomized Study.

Preoperative anxiety can negatively impact patient outcomes by influencing the intraoperative requirements for anesthetics and analgesics, increasing postoperative pain intensity, and augmenting the need for analgesia. Moreover, it may contribute to higher rates of postoperative morbidity and mortality following certain types of surgery. This study investigates the anxiolytic and sedative properties of sublingual melatonin as a premedication agent in young females undergoing cesarean section under spinal anesthesia. A double-blind, randomized, placebo-controlled trial was conducted in Nasiriyah, Iraq. Eighty females were included, 40 in each group, based on specific inclusion and exclusion criteria. Premedication was administered in the morning, 60 minutes before the procedure. In the melatonin group (M), patients received 10 mg of sublingual melatonin, while the placebo group (P) received placebo premedication. Anxiety and sedation levels were evaluated three times: before taking premedication, five minutes before the insertion of the spinal needle, and one hour postoperatively, using the visual analog scale and Richmond Sedation Scale. The results show a highly significant P-value regarding anxiety levels between the M Group and P Group (p-value < 0.001). There was a significant difference in the median sedation scores between the studied groups at pre-spinal insertion and postoperatively (p-value < 0.001). The mean heart rate in the M Group was significantly lower than in the P Group (p-value = 0.0019). Significant differences were noted in systolic and diastolic blood pressures between the two groups, measured five minutes before and after spinal needle insertion (p-value < 0.001). These findings contribute to understanding the impact of sublingual melatonin as an anxiolytic and sedative premedication agent on patients undergoing elective cesarean sections under spinal anesthesia. Further research is warranted to fully elucidate the benefits and implications of melatonin administration in such procedures.

Relationship between intraoperative requirement for anesthetics and postoperative analgesic consumption in laparoscopic colectomy: a randomized controlled double-blinded study.

This study investigated the relationship between intraoperative requirement for an inhalational anesthetic (sevoflurane) or an opioid (remifentanil) and postoperative analgesic consumption. The study included 200 adult patients undergoing elective laparoscopic colectomy. In the sevoflurane group, the effect-site concentration of remifentanil was fixed at 1.0 ng/ml, while the inspiratory sevoflurane concentration was adjusted to maintain an appropriate anesthetic depth. In the remifentanil group, the end-expiratory sevoflurane concentration was fixed at 1.0 vol.%, and the remifentanil concentration was adjusted. Pain scores and cumulative postoperative analgesic consumptions were evaluated at 2, 6, 24, and 48 h after surgery. Average end-tidal concentration of sevoflurane and effect-site concentration of remifentanil were 2.0 ± 0.4 vol.% and 3.9 ± 1.4 ng/ml in the sevoflurane and remifentanil groups, respectively. Cumulative postoperative analgesic consumption at 48 h postoperatively was 55 ± 26 ml in the sevoflurane group and 57 ± 33 ml in the remifentanil group. In the remifentanil group, the postoperative cumulative analgesic consumptions at 2 and 6 h were positively correlated with intraoperative remifentanil requirements (2 h: r = 0.36, P < 0.001; 6 h: r = 0.38, P < 0.001). However, there was no significant correlation in the sevoflurane group (r = 0.04, P = 0.691). The amount of intraoperative requirement of short acting opioid, remifentanil, is correlated with postoperative analgesic consumption within postoperative 6 h. It may be contributed by the development of acute opioid tolerance. However, intraoperative sevoflurane requirement had no effect on postoperative analgesic consumption.

Customised pre-operative cranioplasty to achieve maximal surgical resection of tumours with osseous involvement-a case series.

Surgical resection with bony margins would be the treatment of choice for tumours with osseous involvement such as meningiomas and metastasis. By developing and designing pre-operative customised 3D modelled implants, the patient can undergo resection of meningioma and repair of bone defect in the same operation. We present a generalisable method for designing pre-operative cranioplasty in patients to repair the bone defect after the resection of tumours. We included six patients who presented with a tumour that was associated with overlying bone involvement. They underwent placement of customised cranioplasty in the same setting. A customised implant using a pre-operative imaging was designed with a 2-cm margin to allow for any intra-operative requirements for extending the craniectomy. Six patients were evaluated in this case series. Four patients had meningiomas, 1 patient had metastatic breast cancer on final histology, and 1 patient was found to have an intra-osseous arteriovenous malformation. Craniectomy based on margins provided by a cutting guide was fashioned. After tumour removal and haemostasis, the cranioplasty was then placed. All patients recovered well post-operatively with satisfactory cosmetic results. No wound infection was reported in our series. Our series demonstrate the feasibility of utilising pre-designed cranioplasty for meningiomas and other tumours with osseous involvement. Following strict infection protocols, minimal intra-operative handling/modification of the implant, and close follow-up has resulted in good cosmetic outcomes with no implant-related infections.

Thoracotomy Patients Under General Anesthesia: A Comparison on Intra-Operative Anesthetic and Analgesic Requirements, When Combined with Either Epidural Analgesia or Continuous Unilateral Paravertebral Analgesia.

Regional analgesia is effective for post-thoracotomy pain. The primary objective of the study is to compare the intraoperative requirement of isoflurane and fentanyl between general anaesthesia (GA) with epidural analgesia and GA with paravertebral analgesia. A prospective observational comparative study was conducted on 56 patients undergoing open thoracotomy procedures. The patients were divided into two groups of 28 by assigning the study participants alternatively to each group: Group GAE - received thoracic epidural catheterization with GA, and Group GAP - received ultrasound guided thoracic paravertebral catheterization on the operative side with GA. Intraoperative requirement of isoflurane, fentanyl, postoperative analgesia, stress response, need of rescue analgesics and adverse effects were observed and analysed. 25 patients in each group were included in the data analysis. The intraoperative requirement of isoflurane (32.28 ± 1.88 vs 48.31 ± 4.34 ml; p < 0.0001) and fentanyl (128.87 ± 25.12 vs 157 ± 30.92 μg; p = 0.0009) were significantly less in the GAE group than in the GAP group. VAS scores and need of rescue analgesics and blood glucose levels were not statistically significant during the postoperative period (p > 0.05). The incidence of adverse effects was comparable except for hypotension and urinary retention which were significantly higher in the GAE group. GA with epidural analgesia resulted in significant reduction in the intraoperative consumption of isoflurane and fentanyl in comparison to GA with paravertebral analgesia. However, both the techniques were equally effective in the postoperative period.

Laparoscopic cholecystectomy in a resource limited setting: Factors associated with difficult surgeries at the National Referral Hospital, Bhutan

AbstractBackgroundPrediction of difficult laparoscopic cholecystectomy may help in making necessary arrangements for optimal intraoperative requirements and postoperative care. This study was conducted to examine the factors associated with and outcomes of difficult laparoscopic cholecystectomy performed at the Bhutan's largest hospital in 2020.MethodsThis was a cross‐sectional study with a convenience sampling method. Data on clinical features, ultrasonography and intraoperative factors of patients who underwent laparoscopic cholecystectomy were extracted from their medical records, investigation reports and intraoperative surgery note. Difficult laparoscopic cholecystectomy was defined on the basis of the duration of the surgery, injury to bile duct or artery, or conversion to open cholecystectomy. Data were double entered and validated in EpiData 3.1 and analysed in STATA 13.0.ResultsData from 134 patients were extracted. The mean age of the sample was 43 (±SD 13) years. “Difficult laparoscopic cholecystectomy” was reported in 83 patients (62%) and easy laparoscopic cholecystectomy in 51 patients (38%). Those patients having simple adhesions up to the body of the gall bladder were 1.6 times more likely to encounter difficult laparoscopic cholecystectomy (adjusted PR = 1.60, 95% CI 1.04–2.48, p = 0.034). The majority did not have any post‐operative complications (130 cases, 97%). The indications of laparoscopic cholecystectomy were symptomatic gall stone disease (129, 96%), acalculous cholecystitis (2, 1%) and gall bladder polyp (3, 2%).ConclusionsThe proportion of difficult laparoscopic cholecystectomy is high, but the rates of post‐operative complications were minimal with no mortality or injury to bile duct or arteries.

Analgesic Effects of Magnesium Sulphate as an Adjuvant to Fentanyl for Monitored Anaesthesia Care During Hysteroscopy.

Magnesium sulphate (MgSO4) is conventionally used in the treatment of eclampsia, refractive arrhythmias, asthma, etc. In our study, we aimed to study the analgesic effects of MgSO4 as an adjuvant to fentanyl and reduce the intraoperative opioid requirement to decrease their adverse effects. A total of 122 patients scheduled for hysteroscopy were randomly divided into two groups. Patients in the magnesium group (group A) received intravenous MgSO4 50 mg/kg in 100 ml of isotonic saline over 15 minutes before anaesthesia induction and then 15 mg/kg per hour by continuous intravenous infusion. Patients in the control group (group B) received an equal volume of isotonic saline as a placebo. All the patients were induced with fentanyl and propofol. Perioperative haemodynamic monitoring and postoperative assessment of pain were done. Only 18% of the patients in group A required rescue analgesics as compared to 39.3% of patients in group B. The patients receiving MgSO4 displayed lower verbal numeric rating scale scores in the postoperative period. In addition, the intraoperative requirement of fentanyl (101 (21.33) vs. 144 (28.4) µg, mean (SD)) and propofol (121 (13.3) vs. 140 (16.5) mg, mean (SD)) was significantly lower in group A as compared to that in group B. MgSO4, when administered as an adjuvant to opioids, provided effective postoperative analgesia thereby reducing the need for rescue analgesics. It also decreases intraoperative fentanyl consumption and its dose-related side effects.

Comparison of Intraoperative Low-Dose Ketodex and Fentanyl Infusion for Postoperative Analgesia In Spine Surgery: A Prospective Randomized Double-Blind Study.

Prospective randomized double-blind study. To assess the analgesic effects of the combination of a low-dose ketamine and dexmedetomidine (ketodex) infusion and compare it with that of fentanyl for postoperative analgesia after spine surgeries. Adequate pain management following spine surgeries is crucial. Approximately 57% of patients experience inadequate pain control in the first 24 hours following elective spine surgery, which is attributable to the extensive soft tissue and muscle damage. The study included 60 patients graded American Society of Anesthesiologists I and II and scheduled for thoracolumbar spine surgery involving >3 vertebral levels. The patients were divided into two groups: group KD (ketodex) and group F (fentanyl). The primary objective was to compare the postoperative analgesic requirements among the groups. The secondary objectives included a comparison of the intraoperative anesthetic requirements, postoperative pain scores, hemodynamic parameters, side effects of the study drugs, and the duration of post-anesthesia care unit stay of both the groups. Ketodex use prolonged the mean time to first rescue analgesia (22.00±2.30 hours vs. 11.69±3.02 hours, p <0.001) and reduced the requirement of rescue analgesics in the first 24 hours postoperatively compared to fentanyl use (70.00±8.16 μg vs. 113.31±36.65 μg, p =0.03). The intraoperative requirement of desflurane was comparable between the groups (p >0.05). The postoperative pain scores were significantly lower in the group KD than in group F at most timepoints (p <0.05). Patients in group KD had a shorter post-anesthesia care unit stay than group F did (p <0.001). Low-dose ketodex could be a safe substitute for fentanyl infusion when employed as an anesthetic adjuvant for patients undergoing thoracolumbar spine surgeries involving >3 vertebral levels to achieve prolonged analgesia without any opioidrelated side effects.

Transversus abdominis plane block with ropivacaine provides effective analgesiain patients undergoing total abdominal hysterectomy

: Transversus abdominis plane (TAP) block provides a novel approach for analgesia in abdominal surgery by blocking the sensory nerve supply of the anterior abdominal wall. We evaluated the analgesic efficacy of TAP block with ropivacaine in patients undergoing total abdominal hysterectomy (TAH). 60 adult patients of ASA Grade 1 and 2 undergoing elective TAH were randomized into two groups in this double blind study. All patients received a standard general anaesthetic and before the surgical incision, a bilateral TAP block using the landmark technique was performed with 15 to 20 mlof 0.375% ropivacaine (maximum dose 3mg/kg) (Group R) or saline (Group C). Assessment of hemodynamic parameters and requirement of vecuronium and opioids was noted intraoperatively. Postoperative assessment of pain was performed at regular intervals using visual analog scale (VAS) and categorical pain score (CPS), and total analgesics administered over 48 hrs were noted.: Intraoperative hemodynamic parameters showed significantly lower mean values in the ropivacaine group till 50 minutes and from 80 to 120 minutes after the surgical incision. (p value&amp;#60;0.05). Duration of TAP block was significantly longer in the ropivacaine group (383 mins vs 221mins, p=0.000). Mean intraoperative requirement of fentanyl and vecuronium (p=0.000), and postoperative requirement of diclofenac at 24 hrs (p=0.004) and 48 hours (p=0.007) was significantly lower in Group R.VAS and CPS scores were significantly lower in the ropivacaine group till 2 hours postoperatively(p=0.000). : TAP block with ropivacaine provides effective intraoperative analgesia and decreases postoperative analgesic requirement till 48hours in patients undergoing total abdominal hysterectomy.

Evaluation of Clinical Efficacy of Scalp Block with 0.25% Injection Bupivacaine and 0.25% Injection Levobupivacaine to Blunt the Hemodynamic Response to Skull Pin Insertion during Supratentorial Craniotomies - A Prospective Study

BACKGROUND&#x0D; Head fixation is necessary to maintain the desired head position. Application of skull pins in neurosurgery leads to hemodynamic changes and this sudden change can be prevented by combining general anaesthesia with scalp block which blocks supraorbital nerve, supratrochlear nerve, zygomaticotemporal nerve, auriculotemporal nerve, lesser occipital nerve and greater occipital nerve which are present in superficial and deep layers of the scalp. Several studies have been done to study the efficacy of Injection levobupivacaine and injection bupivacaine in 0.5 % concentrations for scalp block. However, the comparative efficacy of 0.25% injection levobupivacaine and injection bupivacaine for scalp block has not been determined by any study previously. We wanted to compare the efficacy of 0.25% injection levobupivacaine and 0.25% injection bupivacaine in scalp block on the haemodynamic response to head pinning, incision and during craniotomy.&#x0D; METHODS&#x0D; This prospective randomised study included 60 patients of ASA status I or II between age 18–60 years and of either sex who underwent supratentorial craniotomy under general anaesthesia followed by scalp block. Patients were randomly allocated into two groups of 30 each and before application of the Mayfield skull pin head holder, scalp block was given as per group distribution (Group A: 20 ml 0.25% injection bupivacaine and Group B: 20 ml of 0.25% injection levobupivacaine). The hemodynamic responses were recorded at baseline, during scalp block and after head pin insertion, incision and at craniotomy. The total analgesic requirement during intraoperative and post operative period was noted.&#x0D; RESULTS&#x0D; There were no clinically and statistically significant differences in values of heart rate and blood pressure after head pin insertion, skin incision and craniotomy in both the groups.&#x0D; CONCLUSIONS&#x0D; The study revealed that 0.25% injection levobupivacaine when used for scalp block was as efficacious as 0.25% injection bupivacaine. Both the drugs in low concentration of 0.25% were effective in minimizing pressor response to skull pin insertion, incision and craniotomy with less incidence of complication and reduced intraoperative requirement of analgesia.

Evaluation of the Efficacy of Magnesium Sulfate in Reducing Blood Loss in Functional Endoscopic Sinus Surgery: A Randomized Double-Blinded Controlled Trial.

Objectives The primary concern in functional endoscopic sinus surgery (FESS) is maintaining a clear and unobstructed surgical field. Achieving this objective necessitates controlled hypotension, which can aid in the surgical dissection process and reduce the overall duration of the operation. This study aims to evaluate the efficacy of a sole bolus injection of intravenous magnesium sulfate in FESS. The outcomes measured include blood loss, surgical field grading, the additional intraoperative requirement of fentanyl, stress attenuation during laryngoscopy and endotracheal intubation, and extubation time. Methods In this prospective, double-blinded, randomized control trial (CTRI/2021/04/033052), 50 patients scheduled for FESS were randomly divided into two groups: Group M received 50 mg/kg MgSO4 in 100 ml normal saline, and Group N received 100 ml plain normal saline 15 min before induction. The study assessed total blood loss, measured by blood collected from the surgical field and weighing gauze. The surgical field grading was assessed by a six-point Fromme and Boezaart scale. We also observed stress attenuation during laryngoscopy and endotracheal intubation, additional intraoperative fentanyl requirements, and time taken for extubation. The sample size was estimated using the G power calculator 3.1.9.2 (http://www.gpower.hhu.de/). Data were entered in Microsoft Excel (Microsoft Corporation, Redmond, WA) and analyzed using Statistical Package for Social Sciences version 20.0 (IBM Corp., Armonk, NY). Results The demographic data and duration of the surgery were comparable in both groups. The total blood loss in Group M was 100.40 ml ±60.71 ml, which is lower than Group N (133.80 ml ±59.7 ml) with a p-value of 0.016. In addition, the surgical field grading was also better in Group M. The total vecuronium consumption was significantly lower in Group M, which was (7.23±0.84 mg); in Group N, it was (10.64±1.74 mg) with a p-value of 0.0001, respectively. The dosage of additional fentanyl in Group N was 38.46 mcg ± 8.99 mcg, more than in Group M (33.64 mcg ± 11.20 mcg). The time required for extubation was similar in both groups. The duration of the surgery was significantly more significant in Group M (150.0 ±31.36) than in Group N (205.0 ±32.79), with a p-value of 0.0001, respectively. Furthermore, the mean arterial pressure after induction, at 2 min and 4 min after laryngoscopy, was less in Group M, with p=0.001, p=0.003, and p<0.0001, respectively, when compared with Group N. The heart rate after induction, at 2 min and 4 min after laryngoscopy, was also less in Group M, with p=0.016, p=0.003, and p=0.003, respectively, when compared with Group N. The Ramsay Sedation Score was higher in Group M than in Group N's fourth, eighth, and sixteenth hour, with p=0.001, p=0.021, and p=0.001, respectively, in the postoperative period. The sedation score was statistically insignificant after that. No complications were encountered during the study. Conclusion We conclude that a single bolus dose of MgSO4 reduced surgical blood loss more effectively than in the control group. The surgical field grading was also better in Group M, as was the stress attenuation during laryngoscopy and endotracheal intubation. The intraoperative fentanyl requirement was not statistically significant. The time for extubation was similar between the groups. No other adverse effects were encountered during the study.

Characteristics and Outcomes of Liver Transplantation Recipients after Tranexamic Acid Treatment and Platelet Transfusion: A Retrospective Single-Centre Experience.

Background and Objectives: Patients undergoing liver transplantation (LT) often require increased blood product transfusion due to pre-existing coagulopathy and intraoperative fibrinolysis. Strategies to minimise intraoperative bleeding and subsequent blood product requirements include platelet transfusion and tranexamic acid (TXA). Prophylactic TXA administration has been shown to reduce bleeding and blood product requirements intraoperatively. However, its clinical use is still debated. The aim of this study was to report on a single-centre practice and analyse clinical characteristics and outcomes of LT recipients according to intraoperative treatment of TXA or platelet transfusion. Materials and Methods: This was a retrospective observational cohort study in which we reviewed 162 patients' records. Characteristics, intraoperative requirement of blood products, postoperative development of thrombosis and outcomes were compared between patients without or with intraoperative TXA treatment and without or with platelet transfusion. Results: Intraoperative treatment of TXA and platelets was 53% and 57.40%, respectively. Patients who required intraoperative administration of TXA or platelet transfusion also required more transfusion of blood products. Neither TXA nor platelet transfusion were associated with increased postoperative development of hepatic artery and portal vein thrombosis, 90-day mortality or graft loss. There was a significant increase in the median length of intensive care unit (ICU) stay in those who received platelet transfusion only (2.00 vs. 3.00 days; p = 0.021). Time to extubate was significantly different in both those who required TXA and platelet transfusion intraoperatively. Conclusions: Our analysis indicates that LT recipients still required copious intraoperative transfusion of blood products, despite the use of intraoperative TXA and platelets. Our findings have important implications for current transfusion practice in LT recipients and may guide clinicians to act upon these findings, which will support global efforts to encourage a wider use of TXA to reduce transfusion requirements, including platelets.

Duration of Invasive Mechanical Ventilation Post-Liver Transplantation: Does One Size Fit All?

Duration of Invasive Mechanical Ventilation Post-Liver Transplantation: Does One Size Fit All?

A randomized comparative study of preoperative fentanyl and dexmedetomidine nebulization on the hemodynamic response to endotracheal intubation

Background: Intense sympathetic activity is linked to laryngoscopy and endotracheal intubation, which could lead to intraoperative problems. We undertook this study to compare the effects of preoperative nebulized Fentanyl and Dexmedetomidine on hemodynamic response to laryngoscopy and endotracheal intubation, taking advantage of their high bioavailability and better absorption through nasal mucosa. Aim and Objectives: The objectives of the study were (i) to compare the effect of preoperative nebulization on the hemodynamic response to laryngoscopy and intubation; and (ii) to assess intraoperative requirement of anesthetic agents. Materials and Methods: This prospective, randomized, and comparative study was conducted among 100 American Society of Anesthesiologists (ASA) I, II patients (of either gender) undergoing elective surgeries and requiring tracheal intubation, were randomized in two groups. Group A was given Fentanyl Nebulization (2 μg/kg in 4 ml of 0.9% saline) and Group B was given Dexmedetomidine nebulization (1 μg/kg in 4 ml of 0.9% saline) 10 min before anesthesia induction. Hemodynamic parameters were noted before and immediately after induction, 1 min, 5 min and 10 min after intubation. The main goal was to assess how Fentanyl and dexmedetomidine nebulization affect the laryngoscopy and intubation-induced stress response. The secondary outcome was to assess the intraoperative requirement of anesthetic agents, observe adverse effects of study drug and sedation score. Results: Dexmedetomidine nebulization was found to be more effective in blunting rise in heart rate post laryngoscopy compared to Fentanyl Nebulization (P &lt; 0.0001) as well as in MAP after 10 min of intubation (P &lt; 0.0001). Requirement of propofol was seen to be significantly reduced in Group B compared to Group A (P &lt; 0.05). Sedation scores were significantly higher in Group B (P &lt; 0.05). No evidence of side effects was observed in any group. Conclusion: Nebulisation of dexmedetomidine was found to be more effective in attenuation of stress response of laryngoscopy and intubation compared to nebulisation of fentanyl, with stable intraoperative hemodynamic and no significant side effects.

Balanced Blood Product Transfusion during Adult Liver Transplantation

Background: Orthotopic liver transplant (LT) is often associated with massive blood loss and significant transfusion requirements. Recent recommendations for resuscitation strategy in massive bleeding include the transfusion of balanced blood products, fresh frozen plasma (FFP), platelets, packed red blood cells (PRBC), and restricted use of crystalloids. Objectives: To evaluate whether the intraoperative transfusion ratio of fresh frozen plasma to packed red blood cell units (FFP: PRBC ≤1:1 versus &gt;1:1) plays a positive role in reducing PRBC transfusion in LT. Methods: This is a retrospective study of 84 liver transplant recipients who received at least one PRBC unit during the surgery. The patients were grouped into those who received intraoperative FFP: PRBC ratio ≤1:1 (low ratio) versus the ratio&gt;1:1 (high ratio). Selected perioperative variables were compared between the two groups. Results: Patients in the low-ratio versus high-ratio group had lower intraoperative requirements for PRBC (P&lt;0.001). Importantly, in the high-ratio group, the mean postoperative PRBC transfused units were 1.76 times that of the low-ratio group (incidence rate ratio [IRR], 1.76; 95% CI=1.07-2.90). There was a significant difference between the two groups in preoperative body mass index (P=0.047), hemoglobin (P=0.005), and surgical time (P=0.071); moreover, all the variables were higher in the high-ratio group. After adjusting the variables, postoperative PRBC consumption in the low-ratio group was 43% less than that in the high-ratio group (P=0.007). Conclusion: The intraoperative low-ratio transfusion was associated with a reduced need for total PRBC transfusion in LT.